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What's in a Case Formulation?: Development and Use of a Content Coding Manual

Received July 9, 1997; revised October 10, 1997; accepted October 21, 1997. From the Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, Kentucky. Address correspondence to Dr. Eells, University Psychiatric Services, P.S.C., 550 South Jackson Street, Louisville, KY 40202.

A case formulation content coding method is described and applied to the formulation section of 56 intake evaluations randomly selected from an outpatient psychiatric clinic. The coding manual showed good reliability (mean kappa = 0.86) across content and quality categories. Although 95% of the formulations included descriptive infor- mation, only 37% addressed hypothesized predisposing life events accounting for the individual's presenting problems, and 16% included a precipitating stressor. Only 43% inferred a psychological mechanism, 2% inferred a biological mechanism, and 2% mentioned sociocultural factors. Formulations were more descriptive than inferential, more simple than complex, and moderately precise in use of language. In sum, clinicians used the formulation primarily to summarize descriptive information rather than to integrate it into a hypothesis about the causes, precipitants, and maintaining influences of an individual's problems.

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